Updated guidelines for first-line treatment of HIV
HIV virus: guidelines provide evidence-based advice on first-line
treatment |
Updated guidelines, published last week by the British
HIV Association, review recent clinical trial data and provide clearer advice on which nucleoside backbone combinations should be used as first-line treatment in HIV patients.
BHIVA says that a dual nucleoside/nucleotide reverse transcriptase inhibitor
(NRTI) backbone and either a non-nucleoside reverse transcriptase inhibitor
(NNRTI) or boosted protease
inhibitor (PI) should be used in treatment-naive HIV patients. Specifically,
it recommends efavirenz (Sustiva) as the NNRTI of choice and lopinavir
boosted with ritonavir (Kaletra) as the PI of choice.
A comparison between treatment costs has been included in the guidelines
for the first time. BHIVA says that when it believes little distinguishes
drugs apart from cost, this will be pointed out in the guidelines.
The availability of three dual NRTI formulations — Kivexa (abacavir
and lamivudine), Truvada (emtricitabine and tenofovir) and Combivir (zidovudine
and lamivudine) — is likely to affect prescribing choice over single
agents in offering patients the added convenience of reduced pill burden
and dosing. However, the BHIVA guidelines state that it sees no reason
to pay premium prices for combination products rather than use the separate
components. It adds that data suggest Combivir is less well tolerated
than Truvada and produces a lower CD4 count rise than Kivexa and the
extent of its continuing use is likely to depend on the propensity of
zidovudine to produce lipodystrophy, which is costly to treat and associated
with poor adherence. The choice between Kivexa and Truvada requires a
discussion with patients about the side effects of the two combinations,
it says.
The updated guidelines also mention new drugs that are likely to be licensed
in the near future or are already available on compassionate release,
including two PIs and an NNRTI.
Rosy Weston, senior principal pharmacist HIV and sexual health, St Mary’s
NHS Trust, London, told The Journal: “The updated guidelines provide
a thorough evidence-based overview on the use and rationale of antiretroviral
therapy in the treatment of HIV-1 infection in adults. In addition, the
guidelines alert health care providers to areas of pharmaceutical importance,
such as dose modification or requirements for additional monitoring in
specific patient groups. These include patients discontinuing antiretrovirals
with long half lives, patients with hepatitis or tuberculosis co-infection
or those taking concomitant therapy with drugs which may interact with
antiretroviral medicines.” |
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